A Nurse's Story

by Tilda Shalof

  “Isn’t that what our care is already?” I asked.

  “Isn’t that what we’re doing?” Tracy echoed my thought. She was equally dismayed as I was at the deficiency in us that this new title implied. “I mean, how much more patient-centred could our care possibly be?”

  Frances explained. “Well, they gave visiting hours as an example. The trend is to let families visit whenever they like, just walk in, day or night, stay as long as they like.”

  “Haven’t you ever seen some patient’s blood pressure and heart rate shoot up when their relatives come to visit? We see it all the time. The patient is calm and relaxed. The family comes in and turns to us and says, ‘He’s in pain. Do something. Give him a pain killer!’” Nicole said. “Sometimes families need to be kept out to let the patient have rest and privacy, too. Sometimes they start asking the patient questions and fussing and within minutes they’ve got them all riled up and struggling against the tube, oxygen saturations are dropping, and then you have no choice but to sedate them.”

  Only Morty had the guts to raise the other concern that was on everyone’s mind.

  “Hey, if the families are in all the time, when do we get the space we need to do our work, too, without them looking over our shoulders, questioning everything? We all know some families who can be more demanding than the patients.”

  “Oh, yeah, another thing,” said Laura with a sly grin. “You’re going to love this one. We’re supposed to offer families the opportunity to be present during procedures and even during arrests, so that they can see what actually goes on. Maybe if families see what it really entails, they might make more realistic choices. Oh well, food for thought.”

  It was true. We craved food for thought, as well as spiritual sustenance, physical rest, and time away from this demanding work. We had to take good care of ourselves if we wanted to do the work of taking good care of others. Sure, we were tired and hungry, but it wasn’t sleep or food that we needed. What we craved was spiritual regeneration and emotional nourishment in order to do this work properly and cope with its emotional demands. We desperately needed to fill up on whatever the commodity was that became so rapidly depleted within each of us from constantly attending to others’ limitless needs. We needed replenishment of the spirit so that we could go on amid all the sadness and despair that surrounded us and not be downed or drowned by it.

  We had thrived on the emotional support and understanding that we had received from our former manager, Rosemary, who was a nurse to the core. We felt gratified when our patients improved, or we managed to lessen their suffering, or when we were thanked or even acknowledged. But more than anything, what quelled our longings, restored our souls, and satiated our appetites was the emotional and spiritual nurturance that we received from one another. It was what sustained us.

  We debriefed one another after an upsetting encounter with a patient. We shared the horrors of wounds we had seen, patients’ discomforts that we were unsuccessful to ameliorate, and heartbreaking tragedies we had witnessed. Who else but another nurse would understand how such things felt? It was through that understanding that we derived the strength we needed to go forward.

  We took care of each other. We shared secrets and the intimate details of our lives with one another. We understood one another. The work we did made us open up in this way. In fact I believe that this closeness was the very thing that fortified us to do this emotionally demanding work.

  For example, because we knew that Carole had a child with a severe seizure disorder we immediately understood her startled, but then stoic, reaction one night when caring for her patient who was a young man who suddenly started seizing. We knew that Erica was trying to get pregnant, and we took care not to assign her to the critically ill postpartum mother, in case it would frighten her. We now knew of Nell’s serious battle with depression and stopped making fun of her sick calls and outlandish excuses. We sent Ellen off for a nap and covered for her in the middle of a busy shift when she was queasy from morning sickness.

  Tracy guarded her privacy more than most, yet within our small group she had confided to us that she hadn’t seen her mother for years. The mother was a homeless vagrant who roamed the city dragging bags filled with plastic bags and slept in ravines and underpasses. We saw Tracy casually scanning the streets for her when we went out together.

  Nicole shared her qualms with us about her engagement to Andrew, a thoracic resident she’d met in our ICU. (Oliver was long gone, as well as a few others over the years.) She was considering postponing the wedding until she felt more certain. She wasn’t ready, she said. She wasn’t sure he was the one, and she still debated about giving one more all-out attempt to make the pro golf circuit.

  Although Frances was single, she yearned to be a mother. She was thinking of going to China to adopt a baby girl. She was also considering going back to school for her degree in nursing and tried to convince Laura to join her, but Laura wouldn’t budge.

  As for Laura – well, who really knew Laura?

  We knew who was in the closet and who was venturing out. We knew about one another’s pregnancies and attempts at pregnancy, abortions and miscarriages, weight loss and gain; abusive and happy marriages; problematic and brilliant children; credit card indiscretions, stock market killings, flirtations, and flings.

  Some of us even knew Belinda’s secret: her husband had died in our ICU of pneumonia from AIDS.

  “Frances was the nurse caring for him. I’ll never forget it,” she told me one day. “I was working at a different hospital at the time. It was such a blur to me that I didn’t even recognize her when I came to work here. All I remember was her soothing voice. She was so kind and gentle to me when he died. I just lost control of myself and I think I was wailing and screaming. I’m so embarrassed when I think of it now, but I couldn’t help myself. It was then that I decided that this is where I wanted to work one day.”

  She told me this on the day that she was taking care of a patient who was lying in the same bed in which her husband had died. NURSES KNOW THE importance of birthdays. No milestone, for that matter, went uncelebrated, nor any loss unsympathized with. For one of my birthdays, Frances brought in a carrot cake covered with a bright neon-green frosting.

  “Are there any carrots in it?” Nicole asked.

  Frances was known for her improvised recipes. For a potluck dinner at work one night, she had made a lemon meringue pie but, lacking any lemons, substituted oranges.

  “How did you know? I didn’t have enough carrots,” she admitted, “so I used sweet potatoes.”

  Danny Huizinga said he would have just a small slice. “I hope I don’t glow in the dark from that frosting. I must say, Frances, it looks a lot more appetizing than that cake with the cherries on top you made last time.” He chuckled. “I’ve performed lung biopsies that looked more appetizing than that.”

  “Yes, but you did manage to eat two huge slices, as I recall,” said Laura, who looked ready to affectionately slug him or else violently hug him, on behalf of Frances, but we managed to restrain her in time.

  BUT I WAS beginning to worry about the long-term effects of our constant exposure to suffering. At times I felt that the sadness accumulated in us. At times I saw that it deadened us in certain ways and made us hypersensitive in other ways. More and more I saw that nurses were suffering. Nurses needed hope to go on.

  “Who can keep it up for long and remain caring all the time?” Frances asked with a huge sigh.

  I looked at her. “If you can’t keep it up, who can?” I said. “You always say how much you love nursing.”

  “The passion that drives me to do this work is the very thing that’s going to make me leave it in the end,” she answered, wearily.

  Somehow, of all of us, it was Frances who managed to forge a good relationship with the Laurence family. One day they left a box of Belgian chocolates and a note at the nursing station. Thank you to all of the staff caring for Irving.

  And a very special
thank you to Frances (she knows what for).

  Brenda Laurence.

  I asked Frances what she had done to deserve that special mention.

  “All I did was tell her, you do what you believe is right for your husband. Don’t worry what the doctors and nurses say. After all, you and your son know him best. That’s all.”

  I marvelled at the degree to which she had conquered herself.

  There were many times when we felt empty, bereft, overwhelmed by the demands – the emotional ones much more than the physical ones – of being nurses. Sometimes it seemed that the work asked too much of us, not only as nurses, but also as human beings. Who can give so much, so selflessly? In order to do this work you had to be selfless, because to do it properly, you had to become without a self. You might have a self, but you had to subordinate it, obliterate it at times, in order to meet other people’s needs.

  We were not supposed to have our own needs. Yes, we were tired and hungry, but who cared? Certainly not the patients, who were mostly unconscious and totally dependent on us. Definitely not the families, who expected complete devotion from us and seemed to resent it when we took a break or even when we got up to leave at the end of a twelve-hour shift and they had to become accustomed to the style and idiosyncrasies of a new nurse.

  “Are you back tomorrow?” families often asked as your shift was winding down.

  You try to discern from their voice or the expression on their faces if they are relieved or disappointed when you say, no, it’s my day off. You know sometimes they ask for you specifically, and sometimes they ask specifically not for you, and you try not to care one way or the other.

  It wasn’t Florence Nightingale they wanted. The real Florence Nightingale was a hard-nosed battle-axe, a military micro manager, and a slave driver. What they wanted was a sweet, altruistic, loving version of Mother Theresa. So few of us measured up.

  DR. LAURENCE WAS deteriorating quickly. Decisions would have to be made soon or else things would happen in a wild and uncontrolled way. He was heading toward end-stage respiratory failure and severe biological derangement that could only lead to cardiac arrest. Once again we were faced with the ethical dilemma we faced over and over in the ICU. Either we escalate or maintain the same level of care, or we back off and change our goals. That is, either we continue to ramp up the dosages of the medications and number of machines, jack up the tests and procedures, or we could take another tack altogether: gently and gradually withdraw all these things and turn our focus to the patient’s dignity and comfort. Sometimes, the scenario became a showdown. A duel at sundown.

  One member of the family chooses to go all out. They tell us not to hold back with any available intervention or treatment. They embark on this campaign because they believe in the miraculous resilience of the patient, or have endowed medical science with the power to bring about a recovery in all circumstances. At times I think this route is chosen because it is the individual’s way of showing that their love is superior to that of the other family members’. They will be vindicated in the annals of the family history. “See, I told you so,” they must imagine themselves saying one day at a joyful family gathering, “I knew how strong Dad was. You all were ready to give up on him, but thank God, I believed he would make it and I was right.”

  Another faction of the family feels they have to balance the scales by representing the opposite position. This camp has to oppose the other’s aggressive stance in order to declare, “No, it is I who loves Dad best. I will show it by doing the unselfish and compassionate act of letting him go in peace. It is I who truly loves him best, because only I am prepared to make that sacrifice.”

  However, no matter what discussion precedes the course of action, in the end, it is the nurse who puts it into effect.

  Morty was taking care of Dr. Laurence and I was in the room with her, taking care of another patient. Brenda arrived but said she could only stay a few minutes because she had left QT, her poodle, in the car and he would be lonely by himself.

  “Why don’t you send QT in to visit your husband and you stay out in the car?” Morty asked with a straight face, but Brenda was so distracted and distraught, she didn’t even react.

  The weeks had worn on and we had dealt with crisis after complication after setback and all over again. We were keeping Dr. Laurence going. He kept his eyes closed most of the time, but whenever he did open them, he looked heavenward, clasped his hands together, as if entreating us, pleading with us for mercy.

  Howie had stopped coming to visit. He was angry. He called to tell us that he had been removed from the payroll and kicked out of the house.

  Sidney became superstitious and forbade any green bedspreads on his father’s bed. Green was bad luck, he decided. In fact he insisted we write “No Green Bedspreads” in the chart, like a doctor’s order.

  “Another thing,” he added, “I want nobody mentioning cats.”

  Someone had mentioned that his father seemed to have nine lives.

  “If I hear that once more,” he said, “I think I’ll scream.”

  “Are cats bad luck?”

  “Yes! I want Dad to have a hundred lives. I can’t lose him. Don’t you understand that?”

  Brenda found religion. She wore a big golden fish on a chain around her neck, which her spiritual advisor told her would bring the healing powers of the sea – her husband was a Pisces – to his recovery. She brought in a New Age rabbi to visit her husband, to pray over him and give him a new Hebrew name so that the Angel of Death would be foiled and not spirit him away.

  “We must do everything. We can’t give up,” she said to Morty, who was taking care of him one day. I heard her ask, “Can he still hear a prayer? If I recite the Shema into his ear, will he be able to hear it?”

  “Your guess is as good as mine. They say the hearing’s the last thing to go, but if you want the truth, Brenda, I think he’s right out of it.” Morty told it as she saw it.

  Sidney and Brenda refused a family meeting in the quiet room. They preferred to stand out in the hallway and pace back and forth, while the doctors talked to them. I offered them chairs but they both said they didn’t have time to sit. They had to run off to other engagements and had only a few minutes. When Dr. Leung came over to speak with them, Sid was on his cellphone and Brenda was flipping through the pages of her date book.

  “I think we’re coming near to the end of what we can offer your father,” said Dr. Leung, in her gentle, respectful way. “I’m sorry. I would like to put forth to you the idea that in the event your father suffers a sudden cardiac arrest, we do not believe it is in his best interests to resuscitate him.”

  “Are you talking about a do not resuscitate order? Do you mean DNR?” asked Sid. “I talked with my son – he’s a medical student – and we’ve changed our minds. We’ve decided that Dad wouldn’t want to have all of this done.”

  “Oh, yes he would,” Brenda countered. “Your father was never a quitter. He does not give up. You, on the other hand …”

  I decided to speak up from my side of the room.

  “On a number of occasions, when he was conscious and able to communicate, Dr. Laurence indicated to many of us that he didn’t want to continue with treatment.”

  Luckily, I had saved some of the notes that Dr. Laurence had written during his lucid moments, a few days ago when I had last cared for him.

  Let me go. I’ve had enough.

  Enough already.

  I want to die.

  Sid inspected the note. “Yup, that’s Pop’s handwriting, all right.”

  Brenda looked at me, aghast. “I expected more from you, Tilda! As a member of our community, you should know better. It is forbidden to shorten a life. Only God can do that. The rabbi said that the saving of a life is the highest mitzvah! After all the Jewish people have been through, we must save a life at any cost! Pain and suffering is worth it to preserve a life. The rabbi told me –” but she broke off and sobbed into her silk scarf.

&nbs
p; “Not only that,” I pressed on, firm in my resolve that I was doing the right thing, the only thing I was there to do: advocate for my patient, “but other nurses also have heard his wishes, straight from him. Perhaps he hid it from you both but he expressed it clearly to us.”

  Morty nodded to show her corroboration. The doctors listened closely.

  “Well, could you just keep him going until Mitchell and Emily’s wedding?” asked Brenda. “It’s next week, and it would ruin their special day.” She scanned her calendar. “The week after that would work, if you want to do it then.”

  I was speechless. We all were.

  Except Sidney. “You’re so shallow,” he said to his mother.

  “What do we do now?” Brenda said.

  “Pull up a chair,” I said to them. “Hold his hand. Be with him.”

  I sat down and showed them how.

  *Chronic obstructive pulmonary disease.

  15

  NARROW MARGINS AND CLOSE CALLS

  We couldn’t stop talking about what had happened.

  When we weren’t talking about it, we were thinking about it. When we weren’t thinking about it, we were praying it would never happen to any one of us.

  It happened in another hospital and we heard that the nurse was being treated for emotional shock. She was inconsolable.

  What happened was more than an error or a mistake. It was more than a slip or a moment of inattention. It was one nurse’s innocent, but fatally wrong action and it accidentally killed a patient. The scary thing was, any one of us could imagine ourselves doing the exact same thing, in any number of the rushed or distracted moments we’ve all had, in any given shift.

  “The College of Nurses will probably take disciplinary action against her,” said Laura. “She may very well lose her licence over this. One thing’s for sure. She’ll never work in this town again, you’ll see! The coroner will call an inquest and that nurse will be lambasted. That’s the end of her.”